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FIGURE 5-3 PMTCT cascade.
NOTE: ARV = antiretroviral.
SOURCE: Stringer et al., 2008. Used with permission.

PEPFAR’s PMTCT Efforts

Building on the success of the MTCT initiative started by President Bush in 2002, the 2003 authorizing legislation emphasized that MTCT of HIV was largely preventable and directed PEPFAR to support activities for this purpose,25 with the aim of “meeting or exceeding the goal to reduce the rate of mother-to-child transmission of HIV by 20 percent by 2005 and by 50 percent by 2010.”26 In 2008 the reauthorizing legislation added the goal of helping “partner countries in the effort to achieve goals of 80 percent access to counseling, testing, and treatment”27 for PMTCT. PEPFAR was directed to support countries to reach “80 percent of pregnant women for prevention and treatment of mother-to-child transmission of HIV in countries in which the United States is implementing HIV/AIDS programs by 2013” and to promote “infant feeding options and treatment protocols that meet the most recent criteria established by the World Health Organization.”28

PEPFAR’s PMTCT activities have evolved with the changing evidence base, and PEPFAR has endorsed the adaptation of the updated 2010 WHO PMTCT guidelines described above into their programming (OGAC, 2011c). PEPFAR defers to the WHO normative guidelines and itself issues only PMTCT-specific operational guidance. PEPFAR implementers may offer Option A or Option B, and some sites, including several in Malawi, have begun to roll out Option B+, with initial data confirming the feasibility of implementation, though challenges exist (Chinkonde-Nkhoma et al., 2012; Holmes, 2012).

To support the scale-up of PMTCT and pediatric HIV services, PEPFAR currently organizes its activities around addressing three distinct aims mandated by the reauthorization legislation: “a) support HIV testing and counseling for 80% of pregnant women in countries most affected by HIV/

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25Supra, note 3 at img301(a)(2), 22 U.S.C. 2151(d)(1)(E).

26Supra, note 3 at img312(b)(1).

27Supra, note 1 at img101(a), 22 U.S.C. 7611(a)(4)(D).

28Supra, note 1 at img301(c)(1)(E), 22 U.S.C. 2151b-2(d)(1)(F).



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